CMS and Washington State Conspire to Take Emergency Physician Services Illegally
Posted by Myles Riner, MD in Billing and Reimbursement, CMS, Healthcare Insurance on January 26th, 2012
In response to a suit by emergency physicians and hospitals in Washington State that led to a judicial injunction against the State’s plan to restrict Medicaid payment for ED visits, the State of Washington’s Health Care Authority has conspired with CMS to require emergency physicians to provide services to Medicaid enrollees for free. Emergency physicians are required by law (EMTALA) to provide medical screening services (and stabilizing care) to anyone who presents to an emergency department, and these physicians are subject to severe fines and penalties if they fail to provide these services.
CMS is well aware of this obligation, yet this agency has notified the State of Washington that the Medicaid program may ‘proceed under its existing authority to pay for only medically necessary Emergency Room visits’ based on a list of so-called ‘non-emergency diagnoses’ submitted on claims to the Medicaid program in that State (and presumably, other states that want to use the same process). Thus, the federal government is requiring emergency physicians to perform a medical screening evaluation (which can be as simple as a brief history and exam, or as complicated as a full and thorough evaluation to rule out subtle but potentially life threatening medical conditions), but is telling federally-funded state Medicaid programs that they need not pay the emergency physician for this service if it turns out the patient does not have a medical emergency, based on this list of final diagnoses. When a government mandates a service from private individuals, and refuses to pay for that service, this is tantamount an unconstitutional and illegal taking of services, and is surely a violation of the physician’s rights.
Curiously, CMS does not allow Medicaid Managed Care Plans in any state to use a list of final diagnoses to preclude payment to emergency physicians or hospitals for these screening and stabilization services. Many states explicitly require payment for medical screening services even when no medical emergency is detected. It is pretty clear that Washington State’s HCA is pushing back hard on emergency care providers for having the gall to use the courts to defy their authority. Resorting to this kind of abusive policy, knowing that it is likely to undermine the financial viability of the safety net and the ability of emergency care providers to meet the needs of all of Washington’s citizens, goes beyond the pale.
The list of so-called non-emergency diagnoses that WA HCA has come up with provides a clear indication of the extent to which this agency will go. This list includes such diagnoses as: hyposmolality (which can cause coma), hemopthalmos (hemorrhage in the eye), foreign body in the hand (often causes infection), multiple contusions (as in getting a beating), pregnancy, etc. Even if every single one of these diagnoses can be managed in a physician’s office, it is important to understand that to get to these diagnoses, it is often necessary to rule out other conditions that may look very similar, but are far more serious, even life-threatening. Performing a cursory medical screening exam in an ED is a prescription for a very expensive EMTALA violation, a hospital’s loss of the right to treat Medicare patients, and a malpractice suit that can end a career. Requiring emergency care providers to perform these evaluations on Medicaid enrollees, and then refusing to compensate them for the effort (and the risk), is just reprehensible.
This post was also published in The Fickle Finger (www.ficklefinger.net/blog/)
Resources for EMS Trainers Available Online
Posted by Nancy Calaway in Disaster Response, Stroke and STEMI on January 11th, 2012
Help train your EMS team with these free resources developed by ACEP, the National Stroke Association, and Genentech at www.EMS4Stroke.com.
In addition to interactive lessons, an online EMS Toolkit includes these modules:
- What is stroke? — Understand the impact of stroke and identify stroke symptoms
- The role of EMS in stroke assessment and care — Examine goals for EMS response times, become familiar with commonly used stroke scales, and study pre-hospital management of stroke
- Stroke systems of care — Learn about the classes of hospitals that treat stroke, recognize standards for primary and comprehensive stroke centers, and be able to contribute to best practices for stroke according to designated protocols
- Case studies — Practice proper pre-hospital stroke management with examples
Access the course today at www.EMS4Stroke.com.
D.O.A.
Posted by VeronicaB in Rural Emergency Medicine, TheCentralLine.org, Uncategorized on January 10th, 2012
I can handle the abusive drunks. I can handle the tweekers who are “talkin’ to the devil.” I can handle the annoying drug seekers who are being seen for their weekly “dental pain” fix. But what I can’t seem to handle are the “walk in the door with my dead baby” parents.
I understand this was baby number 8 or 9. I know you can’t remember which since you don’t have custody of any of your other children, and sure, that makes it harder to keep track. And, yeah, she was only 2 months old; you hadn’t quite gotten used to having her around. She still hadn’t quite fit into the household routine.
Now, I know, she was a great baby because she slept through the night. And, yeah, who hasn’t put their baby to bed and then not checked on them for 15 hours. As long as they’re not crying, they’re fine, right? Yes, yes, I understand it was quite the family party and no one woke up before noon… or one… or two in the afternoon. I’m sure the baby was safe and sound on the bed with her full bottle from last night.
As for medical care, sure, being weighed once at the WIC office and being told that she’s “nice and healthy” is exactly the same as being seen by a pediatrician. It’s almost as good as getting vaccinated. I know that you’re busy and just couldn’t quite get in to have her seen at the pediatrician’s office, but I am sure all of your child’s health needs were met during that visit so you could get your much-earned government support.
Now, I have to let you know that I will be calling the local police, the coroner’s office, and Child Protective Services. They’re going to be asking a lot of questions. And, I know several of the maternity nurses are going to want some answers, too, when they find out that the “meth-addicted, breeds like a rabbit, that CPS was told about” at the time of your child’s birth is now bringing back that same child in not quite the same condition as when she left.
But seriously now, I don’t mind doing a peri-mortem exam in the E.D. with the coroner’s official. I’ve done physical exams on lots of two month olds. Granted, they are not usually wearing wet, soiled onesies. They usually aren’t stone cold with obvious lividity set in. They generally are not brought in wrapped in foul, cigarette and eau de dog scented blankets. But, I am a professional. I can maintain a clinical distance while performing my duties.
I am good at my job. And, I can make it through the end of my shift. And, through the next shift. That is… until I finally get home… until the night goes quiet… until I start to wonder what good I am doing at all… until I try to go to sleep with your daughter’s half open eyes and opened mouth still burnt in my brain as if asking me silently, “why?”
January Annals of EM audio summary/podcast is posted
Posted by David H. Newman, MD in Annals of Emergency Medicine on January 9th, 2012
This month has the goods, as always. Highlights:
-How cumbersome are the time-related CMS measures?
-Variability in admission rates for pneumonia among EPs
-STEMIs can get to the cath lab quickly even during crowding
-Stroke mimics: very common, or rare? And how often do they bleed with lytics?
-Disagreement between EPs and neurologists in diagnosing TIA
-Dengue fever – one of the biggest prospective studies you’ll EVER see…
-Poison Centers, an increasingly important public health tool, and a half century of evolution
-Snapshot Review: Steroids for Bells Palsy
And more, just tune in. Email any time, annalsaudio@acep.org
Trauma Story
Posted by Tracy Napper in Uncategorized on January 3rd, 2012
I never expected to be touched so deeply by trauma patients and their families.
John Rogers
Over the years I saw and cared for many injured people from babies to grandparents, both in my career as a trauma surgeon and as an emergency physician.
I remember:
the 3 small boys whose throats were slashed by their father because he was mad at their mother
the young woman who had been beaten with a crow bar and then run over by her jealous boyfriend, she broke both arms both thighs and her pelvis
the 16 year old girl who was in a bad car wreck and came in on two ambulances – she was in one and her leg from the mid thigh down was in the other
the young mother who was shot 9 times by her husband in front of their small children
the man who tried to cut his own head off with a chain saw
the 7 year old girl who was shot while trick or treating and blew apart the blood vessels leading to her liver
the two nurses who were identical twins and were shot in the head by the jealous husband of one of them
the man who opened a package bomb at Christmas and blew his hands off
the electrical worker who severely burned both arms to the point they were both amputated above the elbow
the baby burned badly when his mother stuck him in a tub of hot water to teach him a
lesson
and I remember all of the heartbreaking talks with families which became too common and increasingly difficult for me to do
What I learned from all of this was that life can end or change dramatically in a matter of minutes and we should not take anything for granted. Sometimes we forget how lucky we are. I also learned that good trauma care was the only chance most of these people had to survive or to limit the disabilities they will suffer. Part of the success is getting those badly injured to an appropriate facility as soon as possible and the skill and training of the paramedics, nurses and physicians caring for them.
Sometimes it is not possible or safe to transport them directly to a trauma center as they are too badly injured and need to be stabilized first at the nearest hospital. Thus small hospitals are an important part of the system as are the large trauma centers and their personnel needs as much if not more training as their counterparts in more urban centers. Also not every trauma patient needs to go to the trauma center. To do so would overwhelm the trauma center with patients that very well could have been taken care of elsewhere. By flooding the trauma center with those patients take resources and beds away from patients that truly needed to go there. Thus a well functioning trauma system is valuable in directing patients to the most appropriate facility.
What you may not know is that Georgia has no organized trauma system. People are transported haphazardly without much rhyme or reason. There is no system, there is no organization and some people are taken to inappropriate places and others are brought to the trauma center when it was not necessary. The Georgia Chapter has been working diligently on establishing a trauma system in Georgia. We have also recently completed work on a Emergency Procedures Course through an ACEP Chapter Grant. This course is designed specifically for physicians and mid-level providers in smaller and rural facilities.
By the way, of the patients I told you about at the beginning of this story. All of them survived but one, the 7 year old trick or treater. I was her surgeon and she died on the operating table, still with part of her costume on and despite the efforts of everyone in the operating room that night. I will not forget the weeping from the OR nurses. Nor will I forget the absolute look of devastation on her mother’s face when I had the task of telling her that her little girl had died. It is the duty of the most senior surgeon to have these conversations and it is a duty I do not miss.
All the Lonely People
Posted by VeronicaB in Rural Emergency Medicine, TheCentralLine.org on December 29th, 2011
I know that the holidays can get really depressing for a lot of people, but I had three patients over the weekend that really got me depressed because of their situations. I always said that I would never make a good psychiatrist because I would tend to internalize and identify with my patients, and so that’s why I enjoyed surgery so much. There’s quite a bit of distancing that happens when you’re behind a mask looking at a square of skin.
As an E.D. doc, though, we’re up close and personal with a lot of our patients, so it’s back to internalizing and not having the luxury of a sterile sheet between you and your patient.
Patient One crashed their car. They are homeless, so their car is like their home. Everything they own is in there. They had just gotten kicked out of one “fleabag” motel and were on their way to find something better along the coast when they lost control on a curve. Now, all they have is the clothes on their backs. Well, actually in a hospital bag because they were stripped down to a hospital gown when they arrived. They’re bruised and battered and slightly torn. And, they have no one and no where to go. I can discharge them because, luckily, they didn’t suffer any major injuries. But, they have nothing. So they get admitted. Social Work and Discharge Planning can figure out what to do with them in the morning.
They used to have a life, and friends, and a home. But then they were forced to take early retirement from their work. They lost their home and their social network. They can’t afford housing on a fixed income. So they roam… in their car… from place to place.
Patient Two had a nice home, and a wife. Then their wife died and a part of them died too. So they turned to alcohol to help deal with the pain. Soon their nice home deteriorated as did their health. They have a neighbor who checks on them from time to time. Their neighbor brings them in whenever things get too bad. Patient Two can’t see their PCP because they have an outstanding bill, so the E.D. becomes their PCP. Diabetes out of control again? Yep. Bad cellulitis on your legs again? Yep. Anything new? Yep, pressure ulcers on my bottom from not getting up out of my chair for the last three days because my legs felt too bad. Am I going to be admitted? Yep.
Patient Three has a psych history. They’ve been in and out of the system their entire life which is only 50+ years long so far. They have the look of a 90 year old man. A neighbor stopped by because they hadn’t seen them for a few days and found them looking slightly worse than usual. Not eating or drinking. Somehow, though, they continue to smoke despite the rattling cough in their lungs. How the cigarette paper doesn’t just rip their Sahara Desert dry and cracked lips to shreds is beyond me. Must be the warm stale beer that somehow is within reach. Another admission for “Failure to Thrive.” It’s the least I can do.
Three hots and cot… at least for tonight… at least for today…
Anthem (and others) to Cut Payment for E&M-25 by 50%
Posted by Myles Riner, MD in Billing and Reimbursement, Fair Payment/Balance Billing, Managed Care Contracting and Payment on December 20th, 2011
Recently, Anthem in Kentucky (and other states), Harvard Pilgrim, and other plans (so I hear), have established policies to reduce by half payment for Evaluation and Management (E&M) services when accompanied by a -25 modifier and billed in combination with some 150 specific (and commonly used) preventative and procedure codes. The -25 modifier is supposed to indicate that these services are ‘separately identifiable’, according to AMA CPT coding rules. The rationale for this 50% reduction is that the plan does not want to pay twice for ‘the overlap of overhead expenses in the RVUs of the code combinations’. Anthem KY also plans to ‘make improvements in (their) primary care fee schedule allowances for office E&M codes’, but it is not clear to me if these improvements are intended to compensate for some or all of these reductions (don’t count on it).
Initially, I was not sure whether this policy would apply to both office based and facility based providers, so I contacted Anthem in KY to see. Though there was some confusion about this at first, the latest response I got from Anthem KY was that “Emergency Room Physicians will NOT be affected by the 50% reduction in payment”. I do not know at this point whether or not this exception also applies to other facility based providers. When I initially saw the policy statement from Anthem, I replied to them that:
I do not believe that ANY portion of the RVUs assigned to the E&M service should be ignored, deleted, modified, or considered duplicative to the RVUs assigned to the additional procedure when separately identifiable services are coded on the same claim. This is what CPT means by ‘separately identifiable’: it means ‘distinct from’. The overhead expenses associated with an E&M service are likely to be completely separate and independent of the practice or overhead expenses associated with the procedure: incremental rather than overlapping. For example, the major practice expense for an office-based practitioner associated with the performance of an ultrasound is the cost of the machine and the cost of the training to perform the service. Neither of these are necessarily duplicative of, or overlapping with, the practice expenses associated with the provider’s E&M service.
In the case of facility based providers, like emergency physicians, the practice expense component of the E&M services are likewise separate and distinct from the practice expenses associated with procedural services by these providers, AND IN ADDITION, the practice expense component of the emergency physician’s E&M services represent a very small component of the overall RVUs assigned to the E&M service – certainly far less than 50%.
I indicated that this policy was inappropriate whether or not it was applied to office based or facility based providers. It is my understanding that several plans have initiated or are planning to initiate this same sort of payment policy. The AMA has also responded to this development. The fact that Anthem in KY is apparently not going to apply this strategy to emergency physicians, and perhaps other facility based providers, and the argument above against this practice, is an opening that other providers can use to push back when faced with these payment reductions. The unilateral decision by health plans to re-invent or re-interpret CPT claims coding rules on the fly, using rationales that appear more like rationalizations, begs for adoption of standardized, universally applied coding/payment rules for all payers.
This post also published in The Fickle Finger
Annals podcast/audio summary, December 2011: posted!
Posted by David H. Newman, MD in Annals of Emergency Medicine on December 12th, 2011
Highlights:
-Pain severity and ACS: when it hurts more is it also more likely to be ACS?
-Intraosseus versus Intravenous access during cardiac arrest, a randomized trial
-Is discharge after cardioversion of atrial fibrillation safe? A quick lit review
-Lumbar artery hemorrhage in trauma
-What is the yield of MRI for c-spine tenderness AFTER a negative CT scan?
-The ‘Captain Morgan’ technique for hip dislocation
-Progesterone for acute TBI – does it work?
-Computerized order entry: how many are using it?
-Short term death after ED discharge: who’s dying?
-A field kit for diagnosing organophosphate poisoning
Happy Holidays, and email us any time! annalsaudio@acep.org
D&A
Christmas Message
Posted by Marlene Buckler, MD, FACEP in Uncategorized on December 9th, 2011
The following is a little piece I wrote three years ago while working my first locum assignment in beautiful New Zealand. The message is timeless.
THE MAN WITH THE RINGS IN HIS POCKET. A CHRISTMAS STORY
One word frees us of all the weight and pain of life: That
word is love.
Sophocles (496 BC – 406 BC)
In these days leading up to Christmas, one day last week, just prior to going off duty, I attended an eighty-two year old man in the emergency room. EMS brought him to us from his GP’s office because he was having abdominal pain and vomiting. Though a number of benign conditions can cause such symptoms, in the elderly the chances of something serious going on is more likely. It is the same here in Whanganui, New Zealand, where I am currently working, as it is anywhere else in the world.
Pain in the abdomen can result from things as simple as gastritis or a mild viral infection, to life-threatening conditions such as aneurysm, heart attack, appendicitis, pancreatitis, bowel obstruction and a number of other equally serious maladies. The longer we live the more likely we are to acquire a significant medical or surgical problem.
Though the man’s pain had somewhat lessened by the time I saw him, because of his age my suspicions that a serious intra-abdominal condition existed were still fairly high. Physical exam revealed a mildly tender abdomen but little else in the way of positive findings.
My patient lived alone and appeared to be ill-kempt and of limited financial means. His clothes were old and warn and in need of a wash, as was he. A mild rather unpleasant odour accompanied him. On first blush this patient seemed to be just like so many others I have seen in my career.
But as we spoke he revealed himself to be a person of grace and dignity. He was polite, articulate, non-complaining and appreciative of our efforts to make him comfortable and to find out why he was sick. I enjoyed meeting him and the feeling appeared to be mutual. As part of the initial work-up to discover the cause of his symptoms, an ECG, the usual blood tests and x-rays of his chest and abdomen were ordered.
When looking at the x-rays I could see that no one had removed his trousers before the films were taken. There, in the area of the left-sided pocket, was the image of three rings, women’s rings. Why, I wondered out loud, would a man be carrying women’s rings in his pocket?
The radiographer (x-ray technologist), who had just delivered the films to us, told the story.
The man’s wife had died about ten years earlier and he had promised her that he would always keep her rings with him. Over the ensuing years, as he went about his life without his precious wife at his side, he kept in his pocket the material symbols of the love they had shared. Whenever he reached into that pocket, there, at the tips of his fingers, was the reminder of his beloved. I wondered how many times he had drawn comfort and courage from feeling and holding those tiny pieces of metal.
During fall and winter celebrations, whether Ramadan, Hanukkah, Christmas or any other festival of lights and sharing, we traditionally give gifts and spread greetings and wishes of peace and love. Often though, the commercial influences of the holidays overshadow and eclipse the true meaning of such celebrations. It is sometimes difficult to concentrate on the peace and love while dealing with day-to-day pressures and stresses. We easily allow selfishness, anger and fear to permeate and overwhelm the noble message of the season, which is one of camaraderie, tolerance and sharing.
Though millions of presents are bought, wrapped and opened, it is the gift of love that endures. It is the one thing that seems to elude many people but which can be had by the simple act of giving it.
The old man was one of the lucky ones. He did not have great material wealth, in fact he had significantly fewer luxuries and resources than most of us enjoy. But he had loved and been loved by someone whose memory continued to bring him peace and comfort. Can any of us wish for a greater gift than that?
When I went off duty the day I met the man with the rings in his pocket, I left him in the care of the doctor working the evening shift. I later learned that the diagnosis turned out to be gastritis and that the patient had improved and was able to go home.
Patients come and go. But this one left each of us a special gift, for he had demonstrated by one simple act, that love is the one thing that matters most.
May your Holidays and your life be filled with love.
Marlene Buckler, MD, FACEP
www.StayOutOfMyER.com
Walls: 35 Years and I Am Still Not Sorry
Posted by Tracy Napper in Uncategorized on December 6th, 2011
Connie Doyle, MD, FACEP
I am a charter member of the American Association of Women Emergency Physicians (AAWEP) and American College of Emergency Physicians (ACEP) and 35+ years later, I am still “not sorry.” I faced a lot of the barriers growing up in the late 1950′s and early 1960′s with “You can’t be a doctor,” “Why not be a nurse?” and “You’ll just get married and have children.” I did get married and have kids, and so did most of my male colleagues. (At the time this was said to me, I did not think that I would ever marry.)
One of my recommendation letters to medical school said, “When you look at this ‘girl’ you would think that she would be pregnant the first year and drop out,” but then he actually defended the reasons why I would complete school and practice.
The first day of medical school one of my classmates accused me of “taking a man’s place who would support a family.” And I did support my family just as all of my other colleagues did. (The same individual apologized 4 years later.)
As interns, we had to go to the residency director to ask permission to wear pants! Those were mini and micro skirt days and if you were doing CPR on a cart you were giving a show. We received permission and then the hospital whites did not have women’s pants. We were sent to a local department store at the residency expense to get them.
They used to throw the interns into the ER in those days the day after medical school without supervision. Learning by trial and error was not good for patients or good for the educational process, so we got the entire house staff to protest this practice. Attending physicians were hired and some of the senior residents also were allowed to moonlight. That is what started the long road to EM. (There was only one residency in EM when I graduated from medical school.) Our new attending physicians were some of the founding and charter members of ACEP, a new organization headquartered in Michigan.
Those experiences lead to a long and satisfying practice of Emergency Medicine, which I still think is one of the most welcoming and collegial groups with which I have been associated. AAWEP has been a fabulous support for the walls that the house of medicine has put in our way.
Anyway, 35+ years later, and I still am not sorry I chose Emergency Medicine, despite all of the barriers! And I still get, “When are you going to go into practice?” “Are you the nurse?” (No, HE is!) “I didn’t see the doctor!” (Yes, you did see HER!)
